Thursday, September 8, 2011

Doctor My Eyes

Patient Zero

I meant to post an entry earlier this week but was waylaid by a nasty viral infection. Though infection is an occupational hazard of working in the hospital, I'm much more likely to pick up something from my 1-year-old, who in turn picks it up from his daycare, Little Lovin' Petri Dish.

JoJo started coughing and running a fever several days ago, followed by copious oozing from his eyes and nose, finishing up with the dreaded pink eye. Unlike fever, which you can mask for 6-8 hours with Tylenol and ibuprofen, there is no easy way to hide a pink eye from your daycare provider. (For those of you who question my morals and judgment, I admit that the blog name "Bad Mommy" was already taken.) So Joseph was banished to his home, where he ended up infecting three other members of his family instead of the tykes at LLPD, who probably gave it to him in the first place.

By day five, he was already starting to improve, but my husband brought him to the doctor just to get a note okaying his return to daycare. He returned with a note, as well as some antibiotic eye drops. I took the note and tossed the bottle. DO NOT DO AS I DID. ALWAYS TELL YOUR DOCTOR WHEN YOU ARE PLANNING TO DISOBEY HIS OR HER ORDERS.* But I have my evidence-based reasons, and here they are.

Pink eye, or infective conjunctivitis, is caused by viruses about half the time, and bacteria the other half. So automatically you know that antibiotic drops are not going to work in half of patients with conjunctivitis. Unfortunately, it's often hard to distinguish between bacterial or viral causes. There are some clues in the history and exam, but they're not that reliable. You could also swab the eyeball, which is as fun as it sounds, but those results can take days to come back. So most pediatricians just end up prescribing the drops to anxious parents. (You read that right; none of the kids are asking for drops.)

There have been five good randomized, placebo-controlled trials of antibiotics drops for pink eye. In the largest one ("Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: a randomised** double-blind placebo-controlled trial."), 326 children in the UK underwent eyeball swabs, and then were randomized to antibiotic drops or borax water. That's right -- half the kids had to endure an eye poke with a Q-tip, followed by dishwashing detergent. (The harmless, low- concentration borax was added to make the water resemble the active drug.) At the end of a week, there was no difference in the cure rates between the two groups. Even in the subset of patients with confirmed bacterial conjunctivitis, 85% of those on antibiotics were symptom-free at 1 week, compared to 80% on placebo -- a nonsignificant difference. The researchers did, however, find a difference in the duration of illness. Those on antibiotic drops cut short their illness by half a day. Other studies on bacterial conjunctivitis have shown similar results, with antibiotics shortening the duration of illness, with minimal effects on actual cure.

So is a 12-hour reduction in symptoms worth it? Topical antibiotics aren't particularly toxic or expensive. An additional benefit is that antibiotics do clear bacteria faster (as proven by repeated eyeball swabs -- these kids have done their duty for science), theoretically reducing infectivity and getting them back to school or daycare faster. But of course, there are still the downsides of increasing antibiotic resistance and uncommon but potentially serious drug reactions.

In my case, I opted not to treat JoJo because I was convinced he had a virus (you don't typically get fever, cough or runny nose with a bacterial conjunctivitis), and he was already improving. If your kid comes down with pink eye, though, you really should consult with your pediatrician.*** In some severe cases, or in newborns, treatment is mandatory to preserve vision. But if your doctor hands you a prescription for antibiotic drops, make sure to ask him or her, "Do we really need to use this?"

*My lawyer friends made me write this. Also, it's not nice to lie to your doctor.**I did not misspell 'randomised.' The entire country of England does. ***See above.*

5 comments:

Two months ago, I had let my son run the course of his conjunctivitis, knowing it was most likely viral and got the "I would have treated it" look from all of pedi friends. Now that he's in daycare, it's a whole different ballgame though. And as one of my friends put it, polytrim drops are pretty harmless, almost like neosporin for the eyes.

About Me

My name is Stephanie, and I'm the happy but tired mother of two boys (ages 8 and 1) and a girl (age 6). I'm also a general internist who practices in a public teaching hospital in California, and the editor of a medical education website, ProfessorEBM.com. My passion is teaching about evidence-based medicine (EBM) to doctors-in-training. EBM involves critically reading the medical literature and applying it appropriately to patient care. I thought it would be fun and enlightening to examine firsthand the evidence on how best to parent kids. My mission is to debunk bad science and to highlight the gaps in our medical and psychosocial knowledge. But first, a warning: I don't treat children, and my take on the research may or may not apply to your particular kid. Reading this blog shouldn't be a substitute for talking to your pediatrician. Heck, I don't even follow my own advice half the time! Enjoy.